Use of Personal Protective Equipment (PPE) for Pediatric Care in Ambulatory Care Settings During the SARS-CoV-2 Pandemic

The American Academy of Pediatrics (AAP) strongly endorses the uninterrupted care of children during the severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) pandemic in a manner that is safe for pediatricians, office staff, children, and families. The Centers for Disease Control and Prevention (CDC) updated its infection prevention and control (IPC) recommendations for health care personnel and others in health care settings in September 2022. Ambulatory care settings may at times require that staff and individuals visiting the practice who are older than 2 years wear a face mask, such as when community transmission rates are high or other circumstances indicate a more protective approach, as evidence suggests that the spread of SARS-CoV-2 is reduced when all parties in close contact are masking.

Consistent and effective IPC practices need to be continued (including the appropriate use of personal protective equipment [PPE]) to mitigate the risk of infection for all who work or receive care in ambulatory settings. Absences due to illness can be reduced through effective IPC practices. Although the evidence base continues to evolve, this resource offers guidance for pediatric care in ambulatory settings (eg, offices, urgent care centers, school-based or school-linked clinics, and homes).

Evidence suggests that a majority of the transmission of SARS-CoV-2 occurs from an infected individual, whether symptomatic or not, to another individual in close proximity, whether via aerosols or droplets. In high-risk settings, including health care settings in areas of high community transmission or for individuals who are at higher risk for severe COVID-19 illness (or have family members who are at higher risk), universal masking can still be considered as an effective strategy to reduce the spread of SARS-CoV-2.

• Although each practice’s standardized approach must take into account individual practice protocols, staffing, and local and regional epidemiology, the guiding principles for ALL practices should include use of appropriate PPE, hand hygiene, disinfection of equipment and physical facilities, and efforts to promote optimal physical distancing given the types of clinical interactions and procedures.
• Each patient care facility, regardless of size, should have written IPC protocols specific to the setting, patient population served, and types of procedures provided. These protocols must, at a minimum, be consistent with federal, state, and/or local public health guidelines and, when applicable, health care system IPC policy.
• Staff at increased risk for severe illness manifestations related to COVID-19 (or those who have family members in their household who are at risk) should be offered the most protective level of PPE available and may require further mitigation.
• Staff should be trained on the expected use of PPE including face coverings, standard procedure masks, N95 respirators, protective eye wear (eg, goggles, face shields), gloves, and gowns for various care scenarios, taking local public health mandates into account. When SARS-CoV-2 Community Transmission levels are high, the use of masks is recommended for all patient contact; eye protection is recommended when contact with secretions is likely. Contact in high-risk settings, such as caring for someone with known or presumed COVID-19, requires properly fitted N95 or higher respirators and eye protection. Individual healthcare workers may have circumstances or preferred comfort levels when use of higher level of PPE may be appropriate (outside isolation/quarantine periods), and they should be supported in these circumstances.
• If staff are permitted to return to work before meeting all conventional return to work criteria, they should wear a respirator or well-fitting facemask continuously even when they are in non-patient care areas such as breakrooms.

PPE and Risk Mitigation Strategies

• PPE Supply: Availability of masks and N95 respirators is generally adequate at this time. In the event of a shortage, the CDC offers guidance on how to optimize supply.
• Risk Mitigation: In addition to PPE, other IPC measures, including equipment and facility disinfection and engineering controls such as physical barriers (eg, sneeze/cough guards), defined routes for patient flow, increased ventilation and rate of air circulation, and use of high-efficiency particulate air (HEPA) filters, are also important in developing ambulatory practice IPC protocols. See information on protecting workers from the Occupational Safety and Health Administration (OSHA). Hospitals and other health care institutions that use N95 respirators are required by OSHA to implement a Respiratory Protection Program (also see the CDC Toolkit).
• Return to Work after COVID-19 Infection: The CDC has updated guidance regarding when health care personnel can consider returning to work following COVID-19 illness or exposure.

Vaccinated Individuals

Vaccination is still the most effective way to protect against severe COVID-19 disease, hospitalization, and death. That said, vaccinated individuals can still experience infections and can spread SARS-CoV-2 to others. For this reason, the recommendations for PPE use as both source control and individual protection are the same for all individuals, regardless of their vaccination status.

Aerosol-Generating Procedures (AGPs)

According to the CDC FAQ on AGPs), these procedures are those that produce smaller respiratory droplets at higher concentrations, thereby increasing the risk for transmission to people in proximity to the patient. AGPs include procedures that instrument the larynx or trachea (bronchoscopy, laryngoscopy, endotracheal intubation, insertion of a laryngeal mask airway) and those that assist ventilation (noninvasive ventilation including bag-mask, bilevel positive airway pressure [BIPAP] and continuous positive airway pressure [CPAP], cardiopulmonary resuscitation). Patients with a tracheostomy are believed to be high risk for aerosolization of secretions. Sputum induction/cough assist procedures are also considered AGPs. While use of a nebulizer for medication administration and use of high flow O2 are AGPs, it is still uncertain whether aerosols generated with these procedures are infectious. Higher levels of PPE (gloves, gowns, goggles or face shields, and masks/respirators) are necessary for the protection of those treating patients more likely to aerosolize respiratory secretions and/or when performing an AGP. The CDC advises that NIOSH-approved N95 or equivalent or higher-level respirators should be used for all aerosol-generating procedures and to conduct AGPs in a negative pressure room, if available. When performing procedures that could produce expelled droplets of respiratory or oral secretions, tears, or a gag or cough (such as immunizations, injections, oral examinations, or fluoride varnish applications), health care personnel may consider increasing their level of PPE.

PPE Use to Mitigate Risk to Patients and their Family Members

• Hand sanitizer should be available for patients/families use.
• The CDC has provided updated guidance that allows for greater flexibility regarding the use of source control (face masks) in health care settings. Universal masking continues to be recommended in areas of high COVID-19 community transmission. Health care settings in areas with lower COVID-19 community transmission may still choose to recommend that all patients and family members ≥2 years of age who enter a health care facility wear a clean, well-fitting face mask and practice physical distancing when possible, particularly during influenza season or when other respiratory disease outbreaks are occurring. Patients and their families may still wish to wear masks regardless of the policy of the health care facility. See this CDC information on face masks for more information.
• Offices should have a protocol for addressing refusals – from staff or patients – to wear a mask in the facility, if masks are being required.
• Staff should consider the use of PPE to protect CYSHCN who are a higher risk for severe illness, even if the health care facility does not require universal masking. Health care personnel should honor requests made by families to wear a face mask, even when it is not required. See AAP interim guidance on children and youth with special health care needs (CYSHCN) for additional information.

Additional Information

• Project Firstline
• COVID-19 Vaccine: What Pediatricians Can Do Now
• Infection Control Guidance for Healthcare Professionals about Coronavirus (CDC)

Information for Families from HealthyChildren.org

• Face Masks for Children During COVID-19
• The Science Behind COVID-19 Vaccines: Parent FAQs
• Ask the Pediatrician: COVID-19 Roundup